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WESTERN HEALTHCARE INSURANCE TRUSTSeptember 13th, 2019
This is an application for (check one): Effective Date: Vimly Account Number (Internal Use Only): Annual Renewal Existing Employer Change New Participating Employer SECTION I: GROUP INFORMATION EMPLOYER INFORMATION Legal Name of Business Doing Business As (DBA) Business Physical Address City: State: Zip: Mailing PO Box City: State: Zip: Federal Tax ID Number State of Legal Domicile Type of Legal Entity Tax Exempt: YES NO Governmental Entity: YES NO Does your group cover Non-Registered Domestic Partners? YES NO We allow the following Domestic Partnerships. Same Sex Opposite Sex Both Group Benefits Administrator (This contact will be the primary contact for benefit updates and administration) Name & Title Phone: Email: Group Billing Administrator (This contact will be the primary contact for billing updates) Name & Title Phone: Email: Insurance Producer (as applicable) Does your organization use an insurance producer for WHIT plans? YES (if YES, complete t
